A nurse is caring for a client who is receiving radiation therapy to treat lung cancer. Which of the following actions should the nurse take?

Observe for signs of infection

Examine the skin for generalized urticaria

Review laboratory test results for low hemoglobin

Monitor the mouth for signs of xerostomia

Answer and Explanation

The Correct Answer is A

Radiation therapy can cause immunosuppression, which increases the risk of infection. The nurse should monitor the client for signs of infection such as fever, chills, malaise, or purulent drainage.

Examine the skin for generalized urticaria. This is not a common side eﬀect of radiation therapy, as urticaria is an allergic reaction that causes hives or welts on the skin. Radiation therapy can cause localized skin irritation, erythema, or dryness, but not generalized urticaria.
Review laboratory test results for low hemoglobin. This is not a direct eﬀect of radiation therapy, as hemoglobin is a component of red blood cells that carries oxygen in the blood. Radiation therapy can cause anemia, which is a low number of red blood cells, but not necessarily low hemoglobin.
Monitor the mouth for signs of xerostomia. This is not relevant for a client who receives radiation therapy to treat lung cancer, as xerostomia is dry mouth caused by reduced salivary gland function. This can occur in clients who receive radiation therapy to treat head and neck cancer, but not lung cancer.

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Correct Answer is A

Explanation

Montelukast is an oral leukotriene receptor antagonist that prevents inﬂammation and bronchoconstriction in asthma. It is taken once daily in the evening to prevent nocturnal symptoms and improve morning lung function.

"I rinse my mouth after taking this medication." This is not necessary, as montelukast is not associated with oral thrush or dysgeusia, unlike some inhaled corticosteroids.
"I use a spacer device when I inhale this medication." This is not applicable, as montelukast is not an inhaler, but a tablet or chewable form.
"I take this medication when I get an asthma attack." This is not appropriate, as montelukast is not a rescue medication, but a maintenance medication that should be taken regularly to prevent asthma exacerbations. A short-acting beta2 agonist such as albuterol should be used for acute relief of symptoms.

A. Administering a nebulized beta-adrenergic B. Providing immediate rest for the client C. Positioning the client in high-Fowler's D. Initiating oxygen therapy

Correct Answer is A

Explanation

Answer: A

Rationale:

A) Administering a nebulized beta-adrenergic:

In the case of an acute asthma exacerbation, administering a nebulized beta-adrenergic agonist (such as albuterol) is the highest priority. These medications act quickly to relax bronchial smooth muscle, dilate airways, and improve airflow. This intervention directly addresses the underlying bronchospasm and helps to alleviate the acute symptoms of asthma.

B) Providing immediate rest for the client:

While rest is important in managing an acute asthma exacerbation, it is not the immediate priority. Addressing the airway obstruction with appropriate medications is crucial for stabilizing the client's condition before focusing on comfort measures such as rest.

C) Positioning the client in high-Fowler's:

Positioning the client in a high-Fowler's position can help improve lung expansion and facilitate breathing. However, this action is secondary to administering medication that can relieve the acute symptoms of bronchoconstriction. The medication should be administered first to rapidly address the exacerbation.

D) Initiating oxygen therapy:

Oxygen therapy might be necessary if the client shows signs of hypoxemia or severe respiratory distress. However, the immediate priority is to address the bronchospasm with a nebulized beta-adrenergic agonist to improve airflow. Once the acute bronchospasm is managed, oxygen therapy can be implemented if needed to support oxygen saturation.

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A nurse is caring for a client who is receiving radiation therapy to treat lung cancer. Which of the following actions should the nurse take?

Nursing Test Bank

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